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The Pharmaceutical Journal Vol 264 No 7088 p432-433
March 18, 2000 News Feature

NSF for coronary heart disease - how important is it for pharmacists?

National Service Framework (NSF) for coronary heart disease (CHD) (PJ, March 11, p396), pharmacists working in different fields gave The Journal their views on how important the NSF is for the profession and how it will affect their own practice

From a hospital pharmacist's perspective, Ms Christine Oates (senior pharmacist practitioner, Leeds teaching hospitals NHS Trust) said that the NSF was about "providing consistent high quality care from pre-admission, throughout the hospital stay and beyond," for which multidisciplinary team working was key.
Drug use was integral to the treatment of cardiac conditions which meant that the pharmacist was ideally positioned for multidisciplinary team working, said Ms Oates. Also, hospital pharmacists could facilitate the flow of information to pharmacists in primary care and to other disciplines, she said.
A focus of the NSF is cardiac rehabilitation and Ms Oates suggested that this would lead to an expansion in rehabilitation services in both "traditional" post-myocardial infarction services and also in areas such as angina, post-surgery and smoking cessation. "This provides excellent opportunities for the pharmacist both in the direct delivery of medicines and health information to the patient and also in the training of others," she said.
The NSF has both short and long term targets which will need to be audited. Ms Oates said that pharmacists were well placed to be involved in both audit and research.
Ms Oates' views were endorsed by the United Kingdom Clinical Pharmacy Association. It will be having a session at its November symposium titled "NSF: implications for pharmacists".

The aims of the NSF

National service frameworks set national standards for specific diseases. The Department of Health says that the aim of NSFs is to improve health, reduce inequality and raise quality of care. There have been two NSFs published so far, with more planned. The NSF for mental health was published in 1999 followed, last week, by the NSF for coronary heart disease. Future NSFs will be for older people and for diabetes.
The NSF for CHD is a blueprint for tackling coronary heart disease which sets standards for preventing and treating CHD. It sets out 12 standards covering the following areas:

  • Reducing heart disease in the population
  • Preventing CHD in high risk patients
  • Treating heart attack and other acute coronary syndromes
  • Stable angina
  • Revascularisation
  • Heart failure
  • Cardiac rehabilitation

A significant impact

Mr Clive Jackson (director, National Prescribing Centre) said that the NSF would have a significant effect on pharmacy practice. It had important implications for all aspects of pharmacy.
Pharmacist advisors working in health authorities could build elements of pharmaceutical care into SAFFs (strategic and financial frameworks) so that pharmacy was at their core. They could also be involved in assessing health need and performance management. Primary care group/trust advisors would be involved in co-ordination at a local level, he said. They could be involved in audit and monitoring and could also have an educational role. At a practice level, pharmacist advisors would be directly involved in the implementation of changes. They could support the GP, conduct drug reviews with patients, identify patients with risk factors for CHD and could perhaps become involved in running clinics.
Mr Jackson said that health promotion would be an increasingly important area for community pharmacists and they could link into primary care group/trust programmes. Supporting the continuity of care from hospital would also be a function of the community pharmacist to ensure follow-up care.
Hospital pharmacists could provide an important source of information about the drugs recommended in the NSF, such as for thrombolysis and secondary prevention of CHD. They could also influence prescribing and, on the wards, could ensure that the hospital's interpretation of the guidelines was being followed.
The President of the Royal Pharmaceutical Society (Mrs Christine Glover) said last week that pharmacists could make a significant contribution to the delivery of the NSF (PJ, March 11, p397). Her suggestions for pharmacist involvement included prescribing advice, giving lifestyle and medication advice to patients, rehabilitation and identifying patients at risk of CHD.

Potential roles for pharmacists

From the targets and standards set by the Government in the the national service framework for coronary heart disease, The Journal has identified the following areas that pharmacists could consider for future development:

  • Medication reviews - these could be conducted with the patient to identify any problems with their medication. They could be used to check that drugs recommended by the NSF are used and for identifying concordance issues, such as adverse effects or a lack of information about the drug.
  • Post-MI rehabilitation - this could involve both hospital and community pharmacists.
  • Health advice and promotion - subjects suggested by the NSF include: smoking, obesity, diet, exercise, alcohol, stress and physical exercise. Advice could be given on the symptoms of coronary heart disease (CHD) and of other serious conditions linked to CHD, such as diabetes. Establishing smoking cessation clinics is an aim of the NSF and pharmacies are identified as a suitable location for such advice.
  • Health monitoring - monitoring of cholesterol, blood pressure and glucose levels could be conducted in pharmacies.
  • Prescribing advice - advice could be given to primary care groups and trusts and to local GPs. Advice could be given on the content of guidelines and also on costs of medicines.

Primary care implications

Mr Mark Robinson (prescribing manager, Croydon primary care group) said that for pharmacists working with GPs, there would be a "need to negotiate increases in drug budgets". A significant amount of cash input would be required to cover not only statins but also drugs for hypertension and heart failure.
Pharmacists would need to give encouragement and help to GPs "to get them going", said Mr Robinson. Pharmacists could be involved in disease management protocols and identifying patients for GPs. Pharmacists with specialist training could run cardiac care clinics, he suggested.
Dr Susan Lunec (phamaceutical advisor, Redditch primary care group) said: "The NSF will be an essential document for any primary care group pharmacist involved in the production of treatment guidelines for coronary heart disease."

NPA framework

Ms Collette McCreedy (head of practice, National Pharmaceutical Association [NPA]) said that "the main thing is the need to have regard for medicines management". She said that the NPA had produced a pharmacy health improvement framework on coronary heart disease and stroke prior to the publication of the NSF. Much of the framework's recommendations were based on what had been expected to be in the NSF, she said. The NPA hoped that pharmacists could use its framework to influence priorities at a local level.
The NPA's framework includes a list of key contributions which community pharmacists could make. "Health promotion activities underpin the successful implementation of services relating to disease prevention and management and are crucial to success in achieving the NHS targets," the framework says. It recommends the provision of health promotion leaflets and other information on CHD avoidance, and making people aware of healthy lifestyle issues such as diet, smoking, exercise, alcohol, blood pressure, cholesterol level and diabetes. Information should be provided about both local and in-pharmacy screening services, it says, including measurement of blood pressure, cholesterol and glucose. Pharmacists could also become involved in early disease detection by assessing risk factors such as blood pressure, cholesterol, weight, body mass index and family history. The framework suggests that shared care protocols should be included in any initiatives for screening the population and that referral systems should be developed with all professionals involved.
Encouraging medication compliance is another area mentioned by the NPA's framework. It suggests that, where poor compliance is suspected, "a medication review may help to discover the reasons why and put in place a more acceptable treatment regime". Pharmacists could also provide prescribing support to doctors - ensuring patients are treated according to appropriate guidelines, conducting prescribing audit and ensuring doctors carry stocks of medicines for prompt treatment of an emergency MI patient.
The NPA framework also describes the potential benefits of including a community pharmacist when planning arrangements for discharge from hospital. They could ensure GP and pharmacy medication records are up-to-date by transferring new drugs initiated in hospital, removing drugs no longer needed, checking for duplication of prescribed drugs, checking that drugs were titrated to therapeutic doses and confirming that no short courses of treatment were repeated.
Other areas mentioned are responding to symptoms of an MI, disposal of unwanted medicines and provision and support to patients and their families.

Pharmaceutical care issues

Professor Steve Hudson (professor of pharmaceutical care, University of Strathclyde) said that the NSF "highlights the health service drivers that are bringing pharmacists into the team effort needed to make an impact on public health". The NSF recommends the development of rapid access clinics for chest pain. Professor Hudson said that this had pharmaceutical care implications because there was a need to ensure that all patients assessed for cardiac risk did receive appropriate treatment and were then followed up.
In Scotland, the Scottish Intercollegiate Guidelines Network (SIGN) have published recommendations for the management of coronary heart disease (PJ, March 11, p396). Commenting on the SIGN guidelines, Professor Hudson said that a working group of pharmacists had been set up in November, 1999, to advise the Scottish Executive about interpreting clinical guidelines in terms of pharmaceutical care.
"Pharmacists express the need to be part of the movement in search of ‘modern standards and service models' through the language of pharmaceutical care. The strategy of targeting new services to high priority groups is part of Scottish pharmacists' way of converting a large public health agenda into manageable developments," Professor Hudson said.

An important part to play

Responding to the NSF from the patient's viewpoint, Mrs Eve Knight (British Cardiac Patients Association) told The Journal about the role patients would like pharmacists to take. "Pharmacists are an important link in the circle of seamless care that patients want." They provided a "demedicalised, friendly and relaxed atmosphere in which patients can access information and discuss their problems," she said.
Pharmacists could provide information on health risks for people who wanted to keep healthy. Monitoring of, for example, blood pressure and weight could be offered and encouragement provided if lifestyle changes needed to be made. "Pharmacists should also be able to offer cholesterol testing and INR monitoring," she said.
Mrs Knight concluded: "Whether it is prevention or secondary care, I think the pharmacist has a very important part to play. It can only improve standards and concordance and offer a real chance of a healthier quality of life."
Commenting on the importance of the NSF for community pharmacists, a spokeswoman for Boots the Chemists said: "We believe that community pharmacists have a strong contribution for the delivery of the NSF." Pharmacists could give advice on medication, diet and lifestyle, including smoking cessation.
A specific example of where Boots was working in partnership with other health care professionals in the area of CHD was in Newport, Isle of Wight, where a weekly drop-in centre had been set up with nurses. The centre provided patients with advice on all aspects of coronary care, she said.